This document provides an overview of a presentation on new concepts in the epidemiology, diagnosis, and treatment of ADHD in children, adolescents, and adults. It begins with disclosures from the presenter, Louis B. Cady, MD, of past and current financial relationships. The presentation then covers topics such as the increasing prevalence of ADHD diagnosis, diagnostic criteria and symptoms, course and long-term outcomes without treatment, and an overview of treatment options including stimulant medications, atomoxetine, and alpha-2 agonists.

1. New Concepts in the Epidemiology, Diagnosis and
Precision Treatment of ADHD in Children,
Adolescents, and Adults
(Slideshare users: this is an updated cover slide)
Grand Rounds – Saint Mary’s Hospital February 5,
2014
Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute
Adjunct Clinical Lecturer – Indiana University School of Medicine
Department of Psychiatry
Child, Adolescent, Adult & Forensic Psychiatry – Evansville, Indiana

2. Continuing Medical Education Commercial Disclosure Requirement
for Louis B. Cady, M.D.
I, Louis B. Cady, MD, have the following commercial relationships to
disclose:
•Speaker honoraria received from:
• Immunolaboratories, Great Plains Diagnostic Labs, LABRIX
•Speaker’s bureaus (active) for:
• Forest Pharmaceuticals, Sunovion
•Historical data – speaker’s bureau for Bristol-Myers Squibb,
Celltech, Cephalon, Eli Lilly, Glaxo-Smith Kline, Janssen, McNeil,
Pfizer-Roerig, Sanofi!~aventis, Sepracor, Shire, McNeil, Takeda,
Janssen, Searle, Shire, Takeda, Wyeth-Ayerst
This CME presentation is not being underwritten by any
pharmaceutical company, and Dr. Cady is not receiving a
fee or honorarium for presenting it.

3. This is where to follow along
on your tablets and smart
phones, or access the
presentation slides later…
www.slideshare.net/lcady
md
Note – the 7 True/False “Q & A” for CME
documentation of learning are attached at the end
of this presentation with the correct answer
indicated.

4. www.slideshare.net/lcadymd

5. “Truth is a constant
variable.”
– William Mayo, MD. “Dr. Will”
Gonda extension, Mayo Clinic
Building 2004. © Louis B. Cady,

6. Prevalence: how much, and ―why
so much‖?

7. Prevalence & diagnosis

8. (NYT, 12 14
2013)

9. Increased methylphenidate usage for
attention deficit disorder in the 1990’s.
Safer DJ et al. Pediatrics. 1996 Dec; 98(6 Pt 1):1084-8}
• 2.5 X increase in MPH tx between 1990 and 1995
– 2.8% (1.5 million) US youths aged 5-18 received this
medication in mid-1995
• “The increase in methylphenidate…appears
largely related to
– an increased duration of treatment;
– More girls, adolescents and inattentive youths on the
medication
– And a recent improved public image of medication
treatment.”

10. Prevalence data of parent report of ADHD
“CURRENT Dx” by provider
2007
2011
IL
4.8%
7.2%
IN
9.3%
13.0%
KY 10.2% 14.8%
Rates of ADHD diagnosis increased an average of 3% per
year from 1997 to 2006 (CDC Vital & Health Statistics)
http://www.cdc.gov/ncbddd/adhd/prevalence.html accessed 01 26 2014

11. ADHD Stats at 317 years of age.
• 5 million children
(9% for this age
group)
– Boys 12%
– Girls 5%
• Children with fair/poor
health status 2½ X
more likely to have dx.
(8% vs 21%)

12. What does it ―look like‖?
A section for kinesthetic and
visual learners…

15. ADHD – not concentrating
Inferior Orbital pre-frontal cortex
Images courtesy of Daniel Amen, MD – Amen Clinics, Inc.,
Newport Beach, CA

16. ADHD - concentrating

17. ADHD – concentrating, on RX

18. ADD – inattentive, without Rx
ADD – inattentive, on Amph
Images courtesy of Daniel Amen, MD – Amen Clinics, Inc., Newport Beach, CA

19. Diagnostic criteria

20. DIAGNOSIS: FOUR FLAVORS OF
ADHD
314.00 ADHD Predominantly Inattentive
Type*
314.01 ADHD Predominant HyperactiveImpulsive Type*
314.04 ADHD, Combined Type
314.9 ADHD – Not Otherwise Specified
6 of 9 symptoms required for 314.00 &
314.01

21. PATIENT NAME: ___________________________
DATE: __________
Medication status: ( ) pre-treatment? ( ) on Rx? ( ) OFF of Rx?
PATIENT STATUS: CHILD
Check off the symptoms which are unusually troublesome for your child (or YOU, if you
are an adult patient) which are clearly different from what other children or adults
typically experience. PLEASE USE THE BACK SIDE OF THIS FORM TO AMPLIFY ON ANY OF
THE "CHECKED" SYMPTOMS WHICH YOU FEEL I SHOULD KNOW MORE ABOUT.
ATTENTION PROBLEMS
displays failure to give close attention to
details; makes careless mistakes
has difficulty with sustained attention
doesn't listen even when spoken to directly
has REAL trouble following through on
instructions; fails to finish tasks
difficulty organizing tasks/activities
avoids, dislikes, or reluctant to engage in
tasks requiring sustained mental effort
(homework, work projects, etc.)
loses things necessary for tasks/activities
easily distracted by extraneous stimuli
(sounds or sights in the environment)
often forgetful in daily activities
For physician use only RECENT CLINICAL HISTORY:
HYPERACTIVITY, "WIGGLESOMENESS"
PROBLEMS
fidgets with hands or feet, squirms in seat
leaves seat in classroom in which remaining in
seat was expected, or can't stay put at work
runs about; climbs excessively in inappropriate
situations
difficulty playing or engaging in leisure activities
quietly
often was "on the go" as if "driven by a motor"
talks excessively - a "chatterbox"
PROBLEMS BEING IMPULSIVE
blurts out answers before questions are
completed
difficulty waiting your turn
interrupts or intrudes on others (butts into
conversations)
PARENTS: Please feel in your child's
CURRENT DRUG THERAPY... PLEASE LIST!
medication
TAKEN
____________
____________
____________
____________
____________
____________
____________
size of dose WHEN
_________
_________
_________
_________
_________
_________
_________
____________
____________
____________
____________
____________
____________
____________
physician use...
ADHD Diagnostic Symptom Checklist, adapted from DSM-IV, by:
Louis B. Cady, M.D. - 611 Harriet Street - Suite 304 - Doctors Plaza
Evansville, IN 47710 www.drcady.com
– Symptoms present
before age 7 (now 12 in
DSM-5) years
– Impairment from
symptoms present in 2
or
more settings
– Significant social,
academic, or
occupational
impairment
– Exclude other mental
disorders

23. DSM-5 update
• 6 symptoms before
age 7
• 6 symptoms for adults
• 6 symptoms before
age 12
• 5 (FIVE) symptoms
for adults

24. ―The Total Picture‖ diagnostic
pearls [from Steven Grcevich, MD]
• Read comments on report cards!
• Ask siblings: “What’s (s)he like to live with?”
• Ask patient: “When was the last time you got
invited to someone else’s house to play?”
• Ask parents: “Is (s)he involved with any
activities in the community?”

25. Different symptom manifestation:
children through adults

26. Continuation of Impairment of ADHD
Childhood

Adulthood
School failure / underachievement
Becomes
Job failure or underemployment
Multiple injuries
Becomes
Fatal car wrecks / risk
taking
Drug experimentation
Becomes
Drug dependence
ODD / CD
Becomes
ASPD, criminal
involvement
Impulsivity and
carelessness
Becomes
Unwanted pregnancy,
STDs, etc
Repetitive failure
Becomes
Hopelessness,
frustration, giving up
Courtesy of William Dodson, MD – Denver, Colorado

27. ADHD: Course of the Disorder
Inattentio
n
—Age—

28. Earlier Initiation of
Smoking with ADHD
Smoking probability
0.6
0.5
ADHD n=128
Control n=109
0.4
237 6 to 17-year-old
boys
0.3
0.2
0.1
0
0
P<0.003
2
4
6
8
10
12
14
16
18
20
4 year follow-up
Milberger S, et al. J Am Acad Child Adolesc Psychol. 1997;36:37-44.
22
24

29. Increased Lifetime Substance Abuse
in Untreated Adults with ADHD
Lifetime rate of substance
abuse in referred ADHD adults
ADHD (n=239)
60
50
55%
Control (n=268)
P<0.001
40
30
27%
20
10
0
Biederman, et al. Biol Psychiatry. 1998;44:269273.

30. Pharmacotherapy Significantly
Reduces Substance Abuse in Adults
with ADHD
% of study population
40
32
3fold!
30
P<0.001
20
12
10
Unmedicated
ADHD
Medicated
ADHD
Control
(N=19)
(N=56)
10
0
(N=137)
Biederman J, et al. Pediatrics. 1999;104:e20-e25.

31. Horrigan J, et al. Presented at 47th Annual AACAP Meeting:
October 24-29, 2000. New York, NY.

32. What happens if ADHD isn’t treated?

33. Driving behavior and results in 27
clinically referred German adults
• N=27, with initial screen
– 19 studied – initial testing then either:
• 10- kept medication free
• 9 – tx’ed for 6 weeks with MPH
Sobanski E, et al. Driving-related risks and impact of metylphendiate
treatment on driving in adtuls with attenion-deficit/hyperactivity disorder
(ADHD). J Neural Trasm. 2008; 115(2):347-56.

34. Driving behavior and results in 27
clinically referred German adults
• Background findings:
– All ADHD subjects: drove significantly more kilometers
per year
– More often registered by traffic authorities
– Fined more frequently
– Involved in more MVA’s
– Self described driving style as “more insecure and
hectic” than controls.
• A high risk group was delineated with:
– 3-6 MVA’s per ADHD subject
Sobanski E, et al. Driving-related risks and impact of metylphendiate
treatment on driving in adtuls with attenion-deficit/hyperactivity disorder
(ADHD). J Neural Trasm. 2008; 115(2):347-56.

35. Do you want to
treat them?
STUDY CONCLUSIONS:
MPH tx improved
information processing
and sustained visual
attention compared to
baseline and untreated
control groups.
Sobanski E, et al. Driving-related risks and
impact of metylphendiate treatment on driving
in adtuls with attenion-deficit/hyperactivity
disorder (ADHD). J Neural Trasm. 2008;
115(2):347-56.

37. www.billfoster.com - Reviving American Manufacturing, accessed 1 27 2014

38. http://www.scdigest.com/assets/newsViews/08-06-12-2.php accessed 01 27

39. Unemployment, underemployment are
contemporary problems…

41. Psychiatric disorders (lifetime) in adults
with ADHD [multiple sources, % is estimated;
N.B. – this is WITHOUT TREATMENT GROWING UP]
• Substance use disorders (all) 50%
• Anxiety disorders 40%
• Major depression 35%
• Learning disabilities 20%
• Bipolar disorder 10%
• Antisocial disorder 10%

42. Adult ADHD’ers:
• Lower self esteem as
adults
• Lower educational
achievements
• Greater use of ancillary
educational resources
• Greater tobacco and
recreational drug use
• A lifelong pattern of
“consistent
inconsistency.”
Source: David Goodman, MD –
Johns Hopkins Adult ADHD
treatment center

43. 105 Adult ADHD Drivers vs. 64
Controls (CC)
• ADHD’ers self reported:
– More citations (esp. for SPEEDING),
crashes & license suspensions
than CC
• ADHD’ers:
Barkley RA, et al.
J Int.
Neuropsychol
Soc. 2002 (5):655762.
– less attentive, made more errors on
visual reaction task
– Lower scores on driving rules test.
• Driving difficulties: not related to
“ODD”, depression, anxiety, or
frequency of substance use.

44. Drug, drug... who's
got the drug?

45. We are not there yet.

46. Response to Psychostimulants
Meta-analysis of Within-Subject Comparative Trials
Evaluating Response to Stimulant Medications
50
41%
40
Best
Response
(Percent)
Betting
odds:
Amph –
69%
MPH 57%
28%
30
16%
20
10
0
AMP
.
MPH
Equal response to
either stimulant
Arnold et al. J Attention Dis. 2000;3:200.

47. Benefit-Risk Ratio and Efficacy
of Psychostimulants
• Very favorable benefit-risk ratio
– rapid, dramatic results
– low risk of long-term side effects
• Approximately 70% of patients with ADHD will
show a positive response on the first trial of
any one stimulant medication
• If two different stimulant medications are tried,
the response rate increases to ~90%
Greenhill. Child Adolesc Psychiatr Clin North Am. 1995;4:123; Spencer et al. JAACAP. 1996;35:409;
Goldman et al. JAMA. 1998;279:1100.

48. Amphetamines, methylphenidate, and
antidepressants - important differences:
Amphetamine - increases release and decreases uptake at
the DOPAMINE uptake transporter (Seiden, et al., 1993)
–effects release of DA from vesicles.
–also allows dopamine to be released from newly
synthesized pools inside the cell.
–also activates 5-HT receptors (Sloviter, et al., 1978)
–L-amphetamine = 50/50 NERI/DRI (Stahl, 2013)
Methylphenidate - effects release of DA from vesicles only
– inhibits dopamine reuptake, as well.
Antidepressants: inhibit reuptake of NE and DA; do not
cause release. [Atomoxetine = “NRI”]

49. Atomoxetine
• Superior to placebo (but slightly
less effective than MPH)
in large, double-blind, placebocontrolled trial-Heiligenstein, 2000
• Spencer et al. (JCAP 2001)-open study,
30 patients, 75% improved >25%.
HCl
O
N
H
CH3
CH3
SE’s: rhinitis, headache, anorexia, dizziness,
nervousness, somnolence
• Michaelson (Pediatrics, 2001) ATX>PLB, best response
at 1.2 mg/kg/day
• Kratchovil (JAACAP, 2002) ATX=generic MPH, open-label
study, inadequately powered
Heiligenstein et al. Presented at AACAP, October 24-29, 2000
Spencer et al. J. Child Adolesc Psychopharmacol 2001: 11(3) 229-238

50. ―Strattera* [coupled with
fluoxetine or paroxetine] has
been great for our
admissions.‖
-Dr. William Beute, MD
Pine Rest Campus Clinic
Grand Rapids, MI
* Brand name used in this
slide because this is a
direct quote
April 21, 2004
[quoted with permission]

51. “2P, or not
2P…
…that is
interaction.”
NB: Cytochrome p450
2D6:
- This is where
atomoxetine is
metabolized
- It is inhibited by

52. ―Alpha 2a agents‖
• Concept of SUSTAINED RELEASE AGENTS –
generic instant release agents not the same
• Extended release guanfacine – “1,2,3 or 4 mg at
bedtime”
• Extended release clonidine – “0.1 – 0.2mg (ER)
twice daily (a.m. and pm)”
• Both are approved for monotherapy or for add-on
therapy.
• Stimulants seem more potent; alpha-2 Rx seems
to be better for oppositional/defiant symptoms,
either by themselves or in combination therapy.

53. STIMULANTS: Time Course
Considerations
2 Classes: MPH or Amph
Amphetamines
MPH
~4 hrs
MPH
dexMPH
8 hrs
12 hrs
MPH LA
MPH ―CD‖
OROS-MPH D-amp
Dex-MPH SR
4-5 hrs
MPH Patch (12+)
SR Liquid
MPH-12 hrs
7-8 hrs 8-10-12
Dex spans
AMP
salts XR
Mixed
Lisamph salts
dexamph
Cady diagram, 2014 – includes current stimulants

54. KEY TAKE HOME POINT! The drug level must
Plasma Concentration Profiles Associated
ASCEND during the day in order to keep the
withtherapeutic effect STEADY.
Different MPH Delivery Patterns
Concentration (ng/mL)
MPH TWICE DAILY
MPH Oros
6
Flat – MPH sips
5
4
3
2
1
0
0
5
10
15
Time (h)
Simulated plasma methylphenidate concentrations for 20-mg total daily dose delivered by twicedaily (BID), flat, and ascending dosing regimens.
from Swanson J, et al. Clin Pharmacol Ther. 1999;66:295-305.

55. ―Mixed salts of amphetamines,
"handedness,‖ and efficacy
Amphetamine mixed salts contains:
–d - amphetamine sulfate (aka "Dexedrine")
–d,l - amphetamine sulfate
–d,l - amphetamine saccharate
–D,l – amphetamine aspartate
Dextro-amphetamine 2x as effective as lamphetamine
–Smith & Davis, 1977; Janowsky & Davis, 1976

56. The Arnold studies
Randomized, double-blind, placebo controlled
31 children with “MBD” (1976)
Rx: 5 mg of d-AMP; 7 mg l-AMP [difference
d.t. MW's]
CONCLUSIONS (replicated previous 1972 study
of n=11):
–Both agents found effective
–Typically one agent was more effective than the
other for individual children
[Arnold LE, Huestis RD, Smeltzer DJ, et al. Levoamphetamine vs dextroamphetamine in minimal
brain dysfunction. Arch Gen Psychiatry 33:292-301, 1976
Arnold LE, et al. Levoamphetamine and dextroamphetamine: Differential effects on aggression and
hyperkinesis in children and dogs. Am J Psychiatry 130:165-170, 1973]

57. Typically one agent was more effective
than the other for individual children
• d-AMP "appeared non-significantly more
effective"
• slightly better for "over-anxious" children
• l-isomer - 2/3 of children improved
• seemed to be of more benefit to
"unsocialized-aggressive" kids
• 28% of responders preferred the l-AMP form
• “decreased tendency to blunt affect and
produce the „amphetamine look‟ [sic]”

58. Substance Use Disorders:
Drugs of Abuse vs Meds for ADHD
Drugs of Abuse
Medications for ADHD
Used to feel good
Feel nothing or feel bad in
overdose
Users crave the drug
Patients commonly forget to take
medication
Large and ready market exists
Readily available but long-term
use is rare
A “struggle” to get kids to stop
taking them
A “struggle” to get kids to take
them
Courtesy of William Dodson, MD – Denver, Colorado

59. Drug Delivery & Dosing
adjustments

60. OROS MPH – the first player
GI liquid
absorbed
into
osmotic
matrix
pump
MPH
pushed
out the
laser
drilled
hole at
end of
tablet

61. Peaks & troughs…
OROS MPH &
OROS MPH – 18 mg
Illustration from Alza promotional literature

62. Mixed amphetamine salts “XR” system
Immediate-Release Bead
Delayed-Release Bead
Bead Core
Bead Core
Drug Layer
Drug Layer
Overcoating
Release-Delaying
Polymer
Overcoating
50%
50%
Overcoating
Capsule
Available in 5, 10, 15, 20, 25, and 30 mg dosing forms

63. Chemical Structure of Lis-dexamfetamine
O
O
CH 3
H2
N
H2
N
N
H
Rate-limited
OH
+
Hydrolysis
CH3
H2
N
Site of cleavage
NH 2
Lisdexamfetamine
(Prodrug)
NH 2
l-lysine
d-amphetamine
(active)
 Lis-dexamfetamine is a prodrug that is therapeutically
inactive until it is converted to active d-amphetamine in the
body

64. Charged polymer sustained delivery
technology
12 hour sustained release LIQUID MPH

65. Basic MPH 101
• How much to Rx?!
• Old dosing charts show 0.3 – 0.7
mg/kg/dose
– But only “1.5 mg/kg/day”….
• But THREE doses of 0.3 – 0.7 mg/kg/dose
= 0.9 – 2.1mg/kg/day
• THEREFORE, theoretical maximum
should be ―2.1 mg/kg/day‖ (the
―Biederman max‖)
• But what is that really, in “Hoosier-speak”?

66. Cady/Desiderato Factor-Label, DownHome, Good-Ole Boy MPH
Calculation:
1 Kg
2.1mg MPH
=
X
Kg
ONE milligram
2.2 lbs
Lys-dexamph, amphetamine salts,
dex amph, dex-MPH = ½ the
typical amount of
methylphenidate
pound of kid
1mg / lb of kid / day
spread out over 12 hours, OR
About ½ that for
amphetamines or dex-MPH

67. So how much to dose?
• No correlation between plasma level and
therapeutic response:
– Big levels in small kids
– Small levels in big kids
• All medication titrations should be made by
informed, observant clinicians with good
solid follow-up and examinations
• Titrations should be based on
DYSFUNCTION

68. M.D. does not stand for ―minor deity‖
• Start lower than you think you probably should.
• Push it carefully until you get results
– a “just right” therapeutic effect
– absent side effects
• Use the “Biederman max” as a rough rule of
thumb to calculate the “ceiling,” NOT TO START!
• If you have to “break through the ceiling” – think
carefully, document your rationale, monitor
carefully for side effects, HTN, cardiac issues
• Explain both the “Goldilocks” and the “Cinderella”
aspects to patients/parents

69. How to screw it up: a case study
• 1/28/14 – 7 year old child presents for tx
• Oct 2013 – dx’ed with ADHD
• RX:
– Started on 30 mg lys-dexamph from start
• Zombied out for two days
– Dosage reduced to 15 mg. Worked well for 3 weeks.
“I like the way my brain is working.”
– Began hearing voices in his head at night.
• Medication stopped
• Voices persisted over the next 2 weeks, then d/c

70. QUOTIENT ® TESTING

71. Case of the ―disorganized daughter‖
• 7/18/12 – 29 yo MWF presents with classic
hypomania, sleep deprivation and psychosis.
– Known history of opioid abuse and
dependence.
• Per mother: “severe insomnia, mood swings,
periodic fits of rage followed by sadness/crying;
difficulty concentrating; flight of ideas, trouble
managing daily activities; little impulse control”
• Noted to have elevated symptoms of ADHD on
initial rating scales

72. TREATMENT COURSE
• By 8/28/2012, stabilized on:
– Paloperidone 6 mg daily + Benztropine 1 mg
three times daily
– Lamotrigine started with plan to cross titrate.
– Started on PNV with Fe and DHA due to low
iron.
• Further history: used opioids to sleep.
• Essentially psychiatrically stable. Euthymic.
• Viewed as stable enough to take Quotient
test.

75. BADNESS
GOODNESS

76. STATS:
• ATTENTIVE
• Impulsive
• Distracted
• Disengaged
7.5% (!!!) of the time
47.5% of the time
32.5% of the time
12.5% of the time

77. Patient’s response to the Quotient
results:
• “Wow, that’s really bad isn’t it?!”
• Asked if she had had severe problems with
attention in school.
• “Well, there’s actually
something I’ve never told
you…”

78. More history, more treatment
• “I actually used cocaine [therapeutically] before
school( in high school) to concentrate.”
– Set the curve in all of her finals in her junior year.
– Stopped it in her senior year
– Used opioid (Lortabs) throughout college to study and
focus. (“It made me awake and helped me do stuff.”).
• Now concerned about her ability to focus.
• Brother, in law school, recently dx’ed with ADD.
On mixed amphetamine salts. Doing much better.

79. Current status: disorganized daughter
• RX:
– Lurasidone – 80 mg HS (bipolar)
– Lamotrigine – 50 mg per day (bipolar - &
couldn’t go up)
– Vilazodone – 30 mg in the a.m.(for OCD
symptoms)
– Lisdexamphetamine – 50 mg capsule in a.m. for
ADHD
• Supplements:
– L-tyrosine, PNV with Fe and DHA
• Status – perfect function and focus.

80. Key take-aways from this case
• Don’t let a substance abuse disorder give you
a constricted field of logic.
• Affective disorders and ADHD can coexist.
• Frequently ADHD’ers have used illegal drugs
or tried their kid’s stimulant.
• Avoid Puritanical blame/self-righteousness:
– Many ADHD’ers (and affective disorder patients)
fall into alcohol, marijuana, and other drugs in an
attempt to self-treat
• Treat the primary problem first.

81. Need for systems approach

82. At home: Two great ―how to do it‖ books

83. Therapy Axioms: who needs it, when
to do it
• The later a child (or adult) is diagnosed, the
more complications (s)he has had, and the
more conflict – the higher the likelihood of
need for psychotherapy
• The converse applies.
• The higher the level of family dysfunction,
the more the need for:
– “parent training”
– Behavioral therapies, etc.

84. Inventor of NASDAQ screen
– Strong family hx of ADHD
– Dx’ed at 48 yoa
– Interviewed in Time
Square – “Don’t you feel
proud?”
–―Not really – all my
life, people were
telling me I would
never amount to
anything.‖
Quote & identity used by specific
permission of David Goodman,
MD & his patient

86. Note: unstandardized co-efficients
• Prospective 33 year follow up of 135 white boys
with ADHD (w/p CD) in childhood & 136 matched
comparators w/o ADHD
• ―Development of CD/APD accounted for the
relationship between ADHD & risk-taking.‖
from: Olazagasti MAR, et al J Am Child Adolesc Psychiatry 2014, Feb 1.
published online 2013 January 5 doi:10.1016/j.aaac.2012.11.012

87. Integrated: how to avoid over-reliance
on meds
• Smart prescribing!
• School:
– Excellent working relationships with school
– Good teaching
• HOME:
–
–
–
–
–
Diminish “electronic screens” effect
Good home discipline
Good sleep/wake schedules
Good diet
Adequate exercise
• Parent training: parenting, stress tips

88. “There are things
known and there
are things
unknown, and in
between are the
doors.”
- Jim Morrison

89. ―Probably the most interesting period
of medicine has been that of the last
few decades. So rapid has been this
advance, as new knowledge
developed, that the truth of each
year was necessarily modified
by new evidence, making the
truth an ever-changing factor.‖
Plummer
Building lobby.
Photo: © Louis
B. Cady, MD
2004

90. Contact information:
Louis B. Cady, M.D.
www.cadywellness.com
www.tmsrelief.com
Office: 812-429-0772
E-mail: lcady@cadywellness.com
4727 Rosebud Lane – Suite F
Interstate Office Park
Newburgh, IN 47630 (USA)

91. Q & A – and answers
• Previous epidemiological data suggested prevalence of ADHD in 3 –
7% of school-aged children. According to more recent CDC data
(2009) the prevalence is probably around 9% for this group.
– TRUE
• Actually, the reported dx of ADHD by current providers is much higher
in the TriState (Indiana, Illinois, & Kentucky), ranging from
approximately 7 – 15%. (per CDC Vital & Health Statistics, 1997-2006)
-
TRUE
• SPECT imaging, as well as PET and functional MRI, may be a useful
way to look at the living brain and observe functioning.
– TRUE

92. Q & A – and answers
• Here is a comparison and contrast of DSM-IV (in use until
January 1, 2014, and DSM-5 (FIVE) in current use.) Either
ALL of the following statements are true, or ALL of them
are false.
- There are nine symptoms in each domain – nine for
inattentiveness and nine for hyperactivity and impulsivity
– In DSM-IV, the previous diagnosis criteria specified that any symptoms
used for diagnosis much be present before the age of 7 (SEVEN)
– In DSM-V, the current diagnostic criteria specify that the child (or adult)
must have the requisite number of symptoms before the age of 12
(TWELVE).
– The difference between the “cutoff” for diagnosis for ADULTS between
DSM-IV and DSM-5 (FIVE) is that in DSM-IV, for the full diagnosis, you
had to have at least 6 symptoms in either domain, and now in DSM-5
(FIVE) you just have to have FIVE symptoms as an adult to qualify.
ALL of these statements TRUE

93. Q & A – and answers
•
According to common dosing guidelines and the presented “Cady/Desiderato Good Old
Boy Down-Home Guide to Dosing Stimulants,” the theoretical MAXIMUM of
methylphenidate products should be 1 mg of methylphenidate per pound of kid per day,
and amphetamines should be half that: e.g., ½ mg per lb of kid per day.
–
•
TRUE
30 mg of Lisdexamfetamine (brand name = Vyvanse ®)* = 30 mg of amphetamine
equivalents for dosing calculations. [*note – brand name is cited here for this
medication because this medication is not in generic circulation at this time, and most
practitioners will not recognize the generic name.]
–
FALSE (oops – this was not covered this a.m.)
•
•
Explanation: 30 mg of Vyvanse = 10 mg amphetamine; 50 mg Vyvanse = 20 mg amphetamine; 70 mg of Vyvanse = 30
mg of amphetamine. This is a common dosing error by well meaning pediatricians – confusing Vvanse and
amphetamine doses. Sorry for not presenting this.
According to presented data and recommendation, the two longest acting and smoothest
agents in class are lisdexamfetamine and liquid 12 hour sustained release
methylphenidate.
–
TRUE
It was a great pleasure to present to you this morning! Hope the “Q
& A” was helpful. I will be back on April 2nd to present another CME
lecture on the use of TMS (transcranial magnetic stimulation) and
depression.